If you have insurance, we will provide insurance claim filing for your primary insurance plan with which we participate; however, if we do not accept your insurance plan or if a claim is denied or a balance is due, you are responsible for payment of the balanced owed and we expect payment within 30 days from the date we notify you of such determination. It is our policy that we do not take secondary insurance and do not file claims to secondary insurance. It is your responsibility to pay any co-pay, deductible, co-insurance, or any other balance not paid for by the insurance or third-party payer within 30 days. Please note all claims must be finalized before any refunds will be submitted for processing. Refund processing can take up to 30 days to issue. For Obstetrical patients, all claims including delivery must be finalized.

It is the responsibility of the patient/guardian to provide us with current insurance plan information prior to services rendered for accurate billing of services to be filed. You are also responsible for contacting your insurance company to make sure we are in-network with your plan. It is your responsibility to know all the guidelines of your plan requirements regarding authorizations, deductibles, co-payments, and other vital requirements for all services. It is the responsibility of the patient/guardian to obtain any referrals that may be required by the insurance company PRIOR to the scheduled visit. Failure to do so will result in the need to reschedule your appointment and a potential $50.00 late notice rescheduling fee may apply. In consideration of services rendered, you agree to transfer and assign to Celebration Obstetrics and Gynecology all rights, title, and interest in any payment due to you or otherwise payable to you for services rendered.

In consideration of the services rendered, you agree to pay Celebration Obstetrics & Gynecology in accordance with the regular rates and terms of service/costs for Celebration Obstetrics & Gynecology. Unless prior arrangements have been made, payment is due in full at the time services are rendered. You affirm that you are duly authorized as the patient or as patient’s guardian/agent to execute this document and accept its terms.

Patient’s certification authorization to release information and payment request. You certify the information given to Celebration Obstetrics & Gynecology in applying for payment under Title XVIII/XIX of the Social security act is correct. You authorize any holder of medical or other information about you to release to Social Security Administration/Division of Family services or its intermediaries or carriers any information needed for this or a related Medicare/Medicaid claim. You further certify all insurance proceeds pertaining to treatment or services provided shall be assigned to Celebration Obstetrics & Gynecology..

We collect and send specimens to a laboratory for processing. We are NOT responsible for laboratory charges. If you have any questions regarding the laboratory charges, you must call the laboratory listed on the bill.

OB Contract: Any OB contract signed by the patient must be paid by the 28th week of pregnancy. Non-payment of the contracted amount may result in discharge from the practice for non-compliance with our financial policy.

Credit Cards: For your convenience, we will keep your credit card information on file to be used for balances on your account that are your responsibility (co-insurances, co-pays, deductibles), not to exceed $150.00. Your signature on this financial policy will be noted as a signature on file for all credit card transactions.

FMLA: There is a $25.00 fee for FMLA paperwork This fee is due PRIOR to any paperwork being faxed or picked up. There is a $50.00 fee for expedited FMLA paperwork.

Returned Check Fee: A $25.00 fee will be assessed to your account for any returned checks

Cancellation/No Show Policy/Late: A $50.00 fee will be an assessment to your account for “NO SHOW” if you fail to cancel or reschedule an appointment with at least 24-hour notice. A $200.00 fee will be charged for surgeries canceled less than 7 days prior to the surgery date. Patients who arrive late for their appointment will be rescheduled.

You understand and agree that all accounts must be brought current within 30 days of the service that was rendered. After 30 days a late fee charge of $25.00 per month will be assessed. After 60 days the account will be turned over to collection agencies or an attorney for collection. Should this account be referred to an attorney for collection, you will be responsible for reasonable attorney’s fees, court costs, recording fees and collection expenses. You further agree that exclusive venue for any collection action shall be in Osceola County, Florida. You authorize Celebration Obstetrics & Gynecology and hereby give all of its affiliated entities, employees, agents and Independent Contractors permission to call you through the use of dialing equipment artificial voice or similar technology, even if you are charged for the call. You expressly agree that such automated calls may be made by Celebration Obstetrics & Gynecology and all of its affiliates, contractors and agents. With such consent, you specifically waive any claim you may have against Celebration Obstetrics & Gynecology, its affiliates, contractors and/or agents for making such calls, including any claim under the Telephone Consumer Protection Act. You also expressly agree that this provision applies to the use of text messaging. You authorize Celebration Obstetrics & Gynecology, its affiliates, contractors and/or agents to use any cell phone or other telephone number to contact you for any purpose, including collection of an outstanding invoice at the number set forth below. If you have a change in address or telephone number, it is your responsibility to provide Celebration Obstetrics & Gynecology with your updated contact information.

*I have read, understand and agree to Celebration Obstetrics & Gynecology’s Billing and Financial Policy: